Best Cellulite Reduction/Treatment Options

Dr. Larry Nichter
Dr. Larry Nichter

Cellulite is a common term used to describe pockets of bulging superficial fat between fibrous bands that cause skin dimpling and lumpiness. It affects 80–90% of women but does occur rarely in men, even those on a healthy diet and of normal weight. There are many predisposing factors including hormones, genetics, weight changes, and even lifestyle. Cellulite most often appears on the buttocks, thighs, and hips. Its appearance is often called “cottage cheese-like, or “lumpy.” For several decades plastic surgeons and dermatologists have sought a means to predictably treat cellulite which can negatively affect a woman’s self-confidence, beach ware and clothing choices. Finally, and fortunately, there are some good means to minimize Cellulite.

Minimally invasive Options (No stitches required):

Cellfina uses a novel approach to standardizing treatments for more predictable results by stabilizing soft tissue with a vacuum device and guidance application system while the numbing solution is injected and bands are cut with a fine cutting needle-like scalpel that reciprocates dividing the fibrous bands that cause cellulite. In my experience the suction dramatically minimizes the discomfort of the entire procedure. It is a much quicker procedure than Cellulaze, and done under local anesthesia only taking thirty minutes to an hour depending on the amount of cellulite treated. It is the only FDA approved device for two or more years of cellulite reduction. As of this date, Cellfina has a 90% Worth It rating on RealSelf over 24 months. This is the best available treatment option for maximal results in my opinion.

Cellulaze employs a side firing laser to cut the fibrous bands causing skin dimpling from under the skin. As a laser is used, heat is produced which to a degree will cause fat to liquefy. It takes on average 1–2 hours when done under local anesthesia. It is highly dependent on the skill of the user. As of this date its Worth It rating on RealSelf is 54% over 24 months.

After both of these procedures:

  • Some bruising and discomfort are common and varies from person to person. For a few days, small amounts of fluid may leak from incision sites. Your physician may recommend use of a compression garment.
  • Return to normal activities after 1–2 days and resume strenuous exercise after 1–2 weeks.
  • Results will continue to improve for the next 3-12 months.
  • Results can be improved in many cases using additional non-invasive energy source options (Radiofrequency or RF, Laser or Ultrasound) following this procedure such as Velashape 3, ThermiSmooth, Thermage, Ulthera and Endermologie. The most effective of these in my experience is Velashape 3 and ThermiSmooth, and least effective in my opinion is Endermologie. There is no down time for non-invasive procedures.

Drains vs. Drainless Tummy Tucks

Dr. Larry Nichter
Dr. Larry Nichter

Your board certified plastic surgeon is the best person to ask for a specific recommendation if a drain is needed or recommended after your tummy tuck procedure.

I determine whether or not to use drains on a patient-by-patient basis. Often my decision is to use drains if liposuction is done at the same time as a tummy tuck or if an extensive tummy tuck is required, for example, following massive weight loss. In those situations I have found an increased chance of having a fluid collection called a seroma, or prolonged swelling, delaying the final result by weeks. Use of a temporary drain seems to prevent this from happening.

Those plastic surgeons that do not use drains for these more involved surgeries often rely on extra “quilting stitches” internally which lengthens the procedure and requires external elastic garments that may be uncomfortable. These garments, if too snug, can also apply too much pressure on the lower skin flaps, decreasing blood flow with delayed healing or other problems.

The purpose of drains is to remove excess fluid such as tumescent liposuction fluid, irrigation fluid, local anesthesia, blood/serum, etc., so that the superficial skin flap can touch the underlying deep tissue (muscle) to begin the healing process. With drains, I do not find it helpful to use compression garments or binders while drains are in place and sometimes not at all especially for “mini tummy tucks.” This is more comfortable for my patients.

Typically, drains are removed within 10 days but if you had significant liposuction done at the same time, it may be a bit longer. In general when each drain has less than 30 cc’s of drainage over 24 hours they are removed. Have trust in your surgeon’s recommendations but feel free to ask the rationale of their decision.

Best Mommy Makeover Options

Dr. Larry Nichter
Dr. Larry Nichter

For women, having a child life-changing event. The capability to create, foster, and give birth to a child of your own distinguishes women in the human species. The nine-month transformation from a tiny embryo to a human being in itself is a magical event, but it transforms the mother’s body as well, often in a non-favorable direction. A mother goes through many different changes during pregnancy and the birth process. In many cases, areas of a woman’s body may not return to the same shape prior to pregnancy.

Thanks to current medical procedures, mothers are often able to restore their bodies back to their pre-birth shape or even better. After breast feeding is complete and you have fully recovered from pregnancy, there are various steps that can be taken to get your body back into shape. In what is commonly known as the Mommy Makeover — various procedures such as breast augmentation, breast lifts, liposuction, tummy tucks, fat transfer, and other procedures — can be done to get your body back into top condition. Most of these procedures can be done in combination to complete your makeover or can be done in separate steps.

Breasts

In most cases after childbirth, women often find that their breasts become out of shape due to breast-feeding or growth then shrinkage after pregnancy. The breast often loses volume on the top and sags and becomes less firm and out of shape (post-partum involution). This can produce visual changes that women want to fix and improve. With straightforward procedures, breasts can be transformed to the desired state with a variety of techniques including breast augmentation using fat transfer (called California Breast Lift in my practice) or implants with or without a lift. These procedures can give your breasts a natural look and maintain volume that was present prior to pregnancy. Some surveys have stated that up to 90% of patients have found success with these procedures, with remarkable results and happiness.

After breastfeeding and childbirth, mothers often find that excess skin results or the skin around the breasts is loose resulting in sagging. In these cases, a breast lift can also be done to reshape the skin envelope and uplift the areola/nipple position. By itself, this procedure isn’t done to change the size of the breasts, but is done more to affect the contour and firm up the breast skin and underlying breast tissue. Newer, minimal scar breast lift techniques, can affect the breast size if combined with a breast augmentation or reduction procedure to enhance the shape, size, and position of the breasts.

Tummy and Hips

Following pregnancy, women often find that the tummy and hip areas are the main concerns for improvement following delivery. After giving birth, women often try to return to their pre-baby weight and find that even if they lose those pregnancy pounds, that they cannot get their tummies back into the desired shape. A tummy tuck with or without liposuction can be performed in this case to remove excess skin, fat, and tone up your tummy muscles. This tried-and-true procedure in the hands of an experienced plastic surgeon will result in a firmer and smoother stomach. Weakened, stretched, and separated muscles (Diastasis Recti) are reshaped during this procedure and will transform your abdominal wall into a well-toned tummy. Giving birth can result in your abdominal skin and muscles being stretched out of shape. A tummy tuck will reshape it back into its toned natural shape, sometimes even better than before you were pregnant. Liposuction is often done at the same time and the fat removed can be used by transferring it to areas that may have lose volume such as your buttocks (Brazilian Butt Lift) or breasts.

Skin

Most women following pregnancy will get stretch marks but this doesn’t mean you can’t do anything about them. Stretch marks, also called striae, can also occur as a result of pregnancy. The tummy tuck not only reshapes the stomach muscles and skin, but also removes these a large number of stretch marks below the belly button. Certain lasers are also available that can get rid of the redness and shrink the width of stretch marks while improving the texture of your skin. Spider veins or red spots (angiomas) following childbirth can vanish seemingly instantly with special lasers and without downtime afterwards. Prominent superficial veins in the legs and other areas also can occur after having a baby. These can be treated in the office with lasers and injections (sclerotherapy).

Skin tone and texture can also be improved. For example, Cellulite and skin wrinkling can be tightened noninvasively. Likewise, circumferential reduction of the waist and thighs with a series of non painful, non-invasive treatments combining the energy sources of RF (radiofrequency), IR (infrared) aimed at improving the skin and superficial fat (e.g. Velashape III).

Fat

After pregnancy and with age, fat can accumulate in different areas that are resistant to diet and exercise. In concert with the Velashape® treatments, Liposuction or other non-invasive non-surgical fat reduction procedures are often helpful. Whether it’s the tummy, hips, thighs, back, or upper arms, liposuction can get rid of the excess fat collection that occurs after pregnancy. By getting rid of these excess bulges along with a sensible diet and exercise plan, you can get your body back into top shape. Other non-invasive techniques such as CoolSculpt® and newer techniques such as Ultrashape®, and Vanquish® are all possibilities for non-surgical fat reduction. As all techniques work differently make sure you go to an expert plastic surgeon to decide which is best for you. These techniques reshape your skin and body towards to your desired shape and best of all there is no down time and minimal if any discomfort. With regular core exercises, you are well on your way to an “abs of steel six-pack”. Exercise maintenance and a stable weight should give you a life-long result.

Belly Button

Another part of the body that might be affected post pregnancy is the belly button, also called umbilicus. The pregnancy cycle can stretch or distort the belly button area. The tummy tuck can assist with making your belly button smaller, however if this is your only concern, improving your belly button’s appearance via a procedure known as umbilicoplasty is possible. An umbilical hernia usually recognized by an “outie belly button” can also be repaired at the same time and often performed under local anesthesia as an office procedure.

Vaginal and Labial Rejuvenation

Especially following vaginal delivery, and important to femininity and intimacy, sometimes the vaginal area is stretched out and loses optimal tone. This can be corrected with a vaginoplasty to firm up and increase tone to the vaginal canal, giving increased intimate sexual satisfaction to the woman and her mate. Likewise, the labia minora (inner lips) might be overly large as a result of pregnancy or genetics. Labia reduction is corrected with a procedure called labiaplasty. The mons pubis, hair bearing area, often becomes bulky, sags, and shows through clothes following pregnancy. This can be corrected with a “monsplasty” procedure. These procedures are often performed as an outpatient procedure, often at the same time as other mommy-makeover procedures.

Skin Pigmentation

Lastly, persistent darkened skin pigment changes may occur on your face, also called Chloasma or Melasma (“mask of pregnancy”). Tailored medical grade lightening creams, peels, and lasers can be done to help with the discoloration that can occur following pregnancy in the facial and other areas.

Conclusion

All of these mommy makeover procedures and others are done in an effort to regain your ideal image, shape and composure following pregnancy. Just because you’ve had a baby, this doesn’t mean your body should be neglected. You can choose from a combination of procedures to get your body back into shape, firmer, and smoother following pregnancy. As always, consult an experienced board certified plastic surgeon before any procedure, discuss treatment options, as well as recovery time, risks, and possible non-surgical alternatives to surgery. Where the gift of lift is a wonderful thing, a mommy makeover can be the best gift you give yourself after pregnancy.

Diastasis Recti and Its Correction Explained

Dr. Larry Nichter
Dr. Larry Nichter

Diastasis Recti simply means a separation of the paired midline abdominal muscles also called the Rectus Abdominis muscles. Although not dangerous this condition makes your tummy stick out even if you have good core strength. Paradoxically with greater separation of these muscles, when you try to tense your muscles to tighten your tummy the center part bulges between the separated muscles. Here are some simple ways to determine if you have a significant Diastasis Recti: If you have a midline muscle gap of more than a few finger breadths when you contract your muscles and if you have bulging or protrusion in your midline between your muscles, especially if made worse when you contract your muscles. In my experience the vast majority of women after pregnancy have a Diastasis Recti, the same goes for massive weight gain/loss regardless of sex.

Repair of Diastasis Recti is typically done as part of a Tummy Tuck or Mommy Makeover procedure (regardless of technique) and consists of bringing the Rectus Abdominis muscles together by suturing (sewing) the inside edges of the muscle fascia together. I have found that it makes no difference if the suture material is absorbable or permanent, and typically I perform a two layer repair to insure that the correction is secure. Single layer closures may have a higher tendency of dehiscence (separation) that would require reoperation for repair. Although Diastasis Recti Repair can be done endoscopically for minor separations, this is no longer as popular of a procedure as there is a tendency for midline redundant skin unless there is wide undermining. Recovery is similar to most plastic surgical/muscle repair procedures: no heavy lifting or vigorous exercises for 4-6 weeks depending on your plastic surgeons wishes. With core exercises as part of your daily routine following this procedure you are well on your way to develop a “six pack Abs of Steel”.

Dr. Larry Nichter featured in Time Magazine’s Article “Nip. Tuck. Or Else.”

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Hitting newsstands today and Monday is an interesting article featuring Dr. Nichter and his patient, written by Joel Stein for Time Magazine, discussing the evolution of cosmetic surgery and it’s undeniable relevance in today’s world. The article titled “Nip. Tuck. Or Else” points out how thanks in part to social media we are now on the red carpet 24/7 posting pictures of ourselves on Facebook, Instagram, SnapChat, Vine, and more, so it’s imperative to look our best at all times. The social media frenzy is one reason why there has been a spike in the number of non-invasive procedures performed on the younger demographic.  It can certainly be said that no longer are cosmetic procedures just for the aging population.

Here is the full article – Nip. Tuck. Or Else.”

by Joel Stein 

Time Magazine Plastic Surgery Shoot You’re going to have to do it. And not all that long from now. Probably not a full-on, general-anesthesia bone shaving or muscle slicing.

But almost definitely some injections into your face. Very likely a session of fat melting in some areas and then possibly moving it to some other parts that could use plumping. Not because you hate yourself, fear aging or are vain. You’re going to get a cosmetic procedure for the same reason you wear makeup: because every other woman is.

No, it’s not fair that–in 2015, with a woman leading the race for the Democratic nomination for President–in addition to dieting, coloring your hair, applying makeup and working out, you now have to let some doctor push syringes in your cheeks just to look presentable. It’s not fair that you have to put your surgery on your credit card just so the other moms on the playground don’t overestimate your age. It’s not fair that you may risk your life going under general anesthesia just to keep up.

Then again, maybe it’s not fair that some women are born straight-nosed and full-breasted. That some people don’t have trouble staying thin. That workers with above-average looks will make $230,000 more over their lifetime than people who are in the aesthetic bottom seventh, as a study by University of Texas economics professor Daniel Hamermesh found. Maybe it doesn’t feel fair that a man is writing about this, even if more and more males are starting to feel the same kind of pressure that women have dealt with for decades.

“It’s becoming harder and harder to say no without being read as irrational or crazy,” says Abigail Brooks, the director of women’s studies at Providence College, who recently completed research comparing women who undergo antiaging interventions and those whom she calls “natural agers.” The former group described the latter using phrases like “let herself go” and “not taking good care of herself.” Brooks worries that that pressure is not only exhausting but also keeps women forever 21 emotionally. Continue reading “Dr. Larry Nichter featured in Time Magazine’s Article “Nip. Tuck. Or Else.””

The “Skinny” on Non Invasive Body Contouring and Fat Reduction

Dr. Larry Nichter
Dr. Larry Nichter

Body contouring techniques can be separated into non-invasive and invasive techniques.

Liposuction, though “invasive”, still remains the gold standard in body contouring. The procedure uses small suction cannulas sometimes assisted by lasers, ultrasound, propulsive jet sprays, radiofrequency energy or vibrational movement (power-assisted liposuction) to actively remove fat by suction from localized areas of fatty accumulation. Liposuction, also called suction assisted lipectomy or “lipo”, is still by far the most successful and predictable way to quickly, safely and effectively create the contouring figure that you desire. However, compared to non-invasive techniques there is some risk, increased recovery time, and discomfort associated with liposuction. Less invasive techniques involve inserting a Radiofrequency (RF) probe (e.g. ThermiRF™ to melt fat for smaller areas without liposuction, but still has more risk than non-invasive techniques). This has led to the growth of non-surgical, non-invasive body contouring.

Non-invasive body contouring technologies use an energy delivery system to injure, destroy, “convince cells to die slowly over time” or alter the architecture of the fat cells without any incisions or placing any device under the skin, and without performing any surgery. Other techniques that are evolving include injecting a substance to reduce fat (Kythera®, FDA approved to reduce fat under the chin).

The common non-invasive energy types utilized to create non-surgical body contouring include RF, focused ultrasound, infrared, RF-coupled suction and massage, and diode laser energy. These non-invasive energy sources that reduce areas of enlarged fat concentrations such as tummy, hips, thighs, and the back — reducing fat without harming other structures like nerves and blood vessels. Some are more effective than others. For example, Zerona® claims that its cool diode laser has a generalized “whole body” slimming technology by making fat cells leaky rather than using thermal mechanisms or cavitation energy to alter or break apart the fat cell. To scientist physicians like myself, it is hard to believe that low level cool laser light waves will be able to penetrate more than a millimeter or two, much less where the majority of the fat lies. It is no wonder that at the time I write this it is ranked as only having 28% satisfaction rating on RealSelf.

On the other hand, there are many effective non-invasive fat reduction technologies available.

CoolSculpting® is effective but has some discomfort noted by many patients, and the applicator paddle sizes can only treat a few areas at a time, require several treatments (3–5), have to wait between treatments, and takes several weeks to see the full effect and occasionally fat ridges are seen above the treated areas.

UltraShape® by Syneron Candela uses focused ultrasound energy, can treat at three different levels, and the different size applicators can treat just about anywhere on the body and even do lipo-sculpting. It is painless and the results are seen quickly with treatments a few weeks apart (series of 3 is typical, more depending on desires may be recommended). It is great for localized areas.

BTL Vanquish uses RF energy to heat the fatty layer precisely, painlessly and selectively to a temperature that causes fat cells to undergo early cell death (apoptosis) by destroying the integrity of the fat cell. Like other techniques that accomplish the same effect, the body then clears the remnants by the lymphatic system.

The VelaShape III, is new technology and much more effective than its predecessors (VelaShape I and II). It is a non-invasive body shaping device used to reduce cellulite, and reduce (slim) the area around the tummy, back, hips and thighs. The machine combines four different technologies — infrared, bi-polar RF, pulsed vacuum, and massage rollers — to improve skin texture and reduce the overall volume of the treated area. It is often used alone for cellulite reduction but often used in conjunction with the other devices I mentioned to magnify their efficacy by smoothing and warming the tissues and clearing much of the edema and fat breakdown products using as an advanced lymphatic massage device. Please note RF devices cannot be used for patients with pacemakers.

For large areas of troublesome fat collections as well as specific areas of focal fat and accumulation you may be best served by the various forms of liposuction. The non-invasive focal fat contouring technologies now in the market place may not be as effective, but have reduced risk and recovery time. Deciding between these options should be done on a case-by-case basis between patient and physician.

Fat Grafts to Face, Buttocks, Breast and Elsewhere

Dr. Larry Nichter
Dr. Larry Nichter

A person’s own fat may be used to improve the appearance of his or her body by moving it from an area of excess (or where it is less desired, such as the thighs, hips or abdomen) to an area that has lost tissue volume due to aging, trauma, surgery, certain diseases, birth defects, or other causes.

Ideal candidates are in good health, and have excess fat in some parts of the body and too little in other regions. Fat grafting is most often used for the face, breasts and buttocks. Typically, the transferred fat results in a significant increase in volume of the body site being treated.

Fat for lipoinjection, also called fat transfer, is removed from unwanted areas of the body by a narrow blunt tip surgical instrument with side holes, called a cannula, through a small incision. The fat is then cleaned with sterile saline solution before being restored to the body. The fat is then injected into the desired area using either a smaller cannula or needle, or it may be placed directly through an incision. Since some of the fat that is transferred does not remain over time, your surgeon may inject more than is ultimately needed to achieve the desired end result. Over a few weeks, the amount of transferred fat will decrease.

There is a limit of how much fat can be safely injected into one area. The amount of fat that remains over time is variable from patient to patient. For some patients, more fat or other fillers may need to be transferred in a subsequent surgery to maintain or supplement the desired results.

Fat transfer procedures are performed using a local anesthetic, with or without IV sedation or general anesthesia, depending on the extent of the procedure and recommendations of your surgeon.

Alternative Treatments

Alternative forms of nonsurgical and surgical volume management consist of injections of FDA-approved injectable fillers, or occasionally implants.

Fillers include hyaluronic acid “HA” (Restylane, Juvederm), polylactic acid (Sculptra), calcium hydroxyapatite (Radiesse) and other fillers, use of man-made implants or other surgical procedures that transfer vascularized fat from body tissues nearby (flaps).

In general, injectable off-the-shelf fillers and fat are used for smaller areas such as in the face, whereas only fat is used to inject into larger areas such as the buttocks due to the quantity required to make the desired change.

Specific Risks of Fat Transfer Procedures

Every procedure involves a certain amount of risk. When choosing to undergo a procedure, an individual must weigh its risks against its potential benefits. Although the majority of our patients do not experience these complications, you should discuss all of your concerns with your plastic surgeon.

Infection — Infection may occur after any surgery and may rarely occur after fat transfer. The rate of infection increases with the amount of injected fat, but the overall rate still remains very low due to routine use of sterile technique and prophylactic antibiotics. Complication rates are higher in smokers, those with diabetes, and with multiple procedures.

Excessive Bleeding — Although bruising after surgery is common and occasionally prolonged, excessive bleeding is unusual during or after surgery. Unapproved medications and supplements, or strenuous physical activity too soon after surgery, can increase the chance of bleeding and complications in general. It is important to follow your surgeon’s postoperative instructions.

Change in Appearance — Typically the transferred fat loses some of its volume over time and then becomes stable. It is possible that more fat transfer treatments may be needed to maintain the desired appearance. It is important to understand that more than one treatment may be needed for optimal results. Additional costs are associated with repeated treatments.

Firmness and Lumpiness — While most transferred fat results in a natural feel, it is possible that some or all of the fat may become firm, hard, or lumpy. If some of the fat does not survive the transfer, it may result in fat necrosis (death of transferred fat tissue), causing firmness and discomfort. Oil cysts may also form at the site of the transferred fat. Needle aspiration or surgery may be required to improve such conditions.

Fluid Accumulation (Seroma) — After fat grafting with or without implant placement, body fluids occasionally collect beneath the skin called a seroma which can delay wound healing. If the fluid accumulation is significant, your plastic surgeon may aspirate the fluid with a small needle as an office procedure one or more times.

Fat Absorption Viability — Approximately 20-40% of injected fat does not remain and re-absorbs. Fat survival depends on the location of injection, age, co-morbid disease factors, smoking, weight gain or loss, and technical factors including expertise of the surgeon. Gentle massaging over the buttock area helps even out and smooths these areas during the recovery phase.

Skin Irregularities or Dimples — Contour irregularities, including bumps, dimples, and asymmetric fullness, as well as depressions or fullness in the skin may occur after fat transfer and liposuction. Visible and palpable wrinkling of skin may occur depending on skin elasticity. Postoperative massaging is often helpful in smoothing these areas.

Fat Necrosis — The areas where fat is transferred to and from may experience fat compromise or fat death that can lead to surface irregularities or result in fat calcification and produce areas of palpable firmness, “bumps”. Additional surgery to remove areas of fat necrosis may be necessary. This may result in contour irregularities.

Skin Loss (Skin Death) — This is a rare occurrence. The skin about the site of surgery or at the incision site may become necrotic or ‘die’. When this happens, skin may change color and slough off. If it is not a full thickness injury the skin will grow back, otherwise a wound will form and heal slowly. This may require further surgical and medical management.

Contour Asymmetry — The two halves of the body are never symmetric. Therefore, following fat transfers, these asymmetries may persist and appear as difference between the contour and volume of the two sides.

Long Term Effects — Subsequent changes in the shape or appearance of the area where the fat was removed or placed will occur as the results of aging, weight loss or gain, or other circumstance not related to the fat transfer procedures.

Fatty Cyst Formation — The transferred fat may form small fat clumps or oil cysts. This may interfere with the interpretation of future radiologic studies of breasts, and rarely, may need to be aspirated or removed.

Fat Transfers to Breast — Fat transfers have been widely used to improve the appearance of breast reconstruction. There are some potential concerns with regard to breast cancer detection. Since the transferred fat may become firm and cause lumps, it may be necessary to have radiological studies performed to be sure these lumps are not due to cancer. However, there is presently evidence nor nor reason to believe that fat transfer procedures may cause breast cancer.

Picking the Best Plastic Surgeon: Finding Dr. Right

The most critical decision to be made in achieving the best plastic surgical result is picking the most experienced and talented, that is the best, plastic surgeon possible. Too often, patients choose a physician based on a catchy ad, the brand name of a technique, the basis of one or two before and after photos, or their web site’s search engine ranking. These criteria will not find the most experienced and talented plastic surgeon.

My Background

Dr. Larry Nichter

I have been a practicing plastic surgeon for more than 25 years, having trained scores of plastic surgeons as a tenured professor of plastic surgery at USC, and I have had a private practice in Orange County since 1993. Speaking from all this experience, here is my advice and the criteria I would use to find the best plastic surgeon in Orange County, Los Angeles, California, or anywhere in the United States. These are the criteria I would use to select a plastic surgeon for my friends, my family, or myself.

First, I want to stress some general observations I have found to be true over the years.

Caveat Emptor: Buyer Beware

The longer a surgeon trains at his craft, the finer his skills and the better his judgment become. Board certification in Plastic Surgery (see below) is a bare minimum. Board certification in an additional surgical field recognized by the American Board of Medical Specialties, or for that matter “triple-board certified,” attests to a doctor’s advanced training and skill and judgment. It also means that they have attained Chief Resident Status in more than one field during their training which means they essentially ran a large departmental service and had senior decision-making and independent operating responsibilities. It is this step that is most maturing for a surgeon.

The institution where the surgeon trained is also important. More renowned schools usually attract the best faculty.

You can use the internet to research the background of a prospective plastic surgeon quickly. Please do this prior to making an appointment. “Just because you wear a baseball cap it doesn’t mean you are a good ball player.” The same applies to anyone wearing a white coat—it doesn’t make you a plastic surgeon, much less a great one.

Caveat Emptor in Latin means “Buyer Beware.” In most states, including California, any physician with a medical school diploma and state license is viewed as a doctor and a surgeon—even without any formal surgical training. In some cases even doctors who have completed only the minimal requirements (medical school, licensing examination, and a one-year internship that need not include surgical training) are touting themselves as “cosmetic surgical experts.” They make these claims of expertise despite the fact that they are only formally trained as family practitioners, OB/Gyns, emergency physicians, dermatologists, or ear-nose-throat specialists. Even physician assistants and nurses have made such claims.

7-Step Process for Finding the Best Plastic Surgeon

The following are my screening guidelines and criteria for picking the best plastic/cosmetic surgeon.

1. Board Certified Plastic Surgeon by the American Board of Plastic Surgery

The American Board of Plastic Surgery is the only certifying board in Plastic Surgery that is a member of the American Board of Medical Specialties. Use these links to look up a prospective surgeon’s status.

To become a plastic surgeon certified by the American Board of Plastic Surgery requires a minimum of five years of surgical training with a minimum of two years of training specifically in plastic surgery. Then the applicant must also pass a comprehensive written board exam. If successful, the candidate must present his/her clinical cases for critical review by board examiners (I was one such board examiner) and if accepted will take a series of oral examinations.

Since the 1990s, the American Board of Plastic Surgery Certification is only valid for ten years. To retain your board certified status, a plastic surgeon must complete a Maintenance of Certification including written testing and case review. This means that all who pass are trained and experienced in all plastic surgery procedures including facial procedures, breast, and body; essentially all cosmetic and reconstructive procedures.

If a Plastic Surgeon is additionally board certified by another surgical specialty recognized the American Board of Medical Specialties, then this also marks additional expertise and training at the highest level. The American Board of Facial Plastic Surgery (ABFRS) is not a licensing body nor an educational institution and the certificates it issues are not legal licenses to practice facial plastic and reconstructive surgery. The ABFRS is not recognized by the American Board of Medical Specialties (although it does note additional specialty training/interest in facial aesthetic surgery).

Likewise, beware of physicians armed only with certification from other non-ABMS recognized boards or special society memberships other than those I have recommended (eg. “Cosmetic Surgery Board,” “Lipoplasty Society of North America,” etc.).

2. Fellow of the American College of Surgeons: FACS

The American College of Surgeons is dedicated to improving the care of the patient and to safeguarding standards of care in an optimal and ethical practice environment. Members of the American College of Surgeons are referred to as “Fellows.” The letters FACS (Fellow, American College of Surgeons) after a surgeon’s name mean that the surgeon’s education and training, professional qualifications, surgical competence, and ethical conduct have passed a rigorous evaluation, and have been found to be consistent with the high standards established and demanded by the College.

To be a member you have to:

  • be board certified in a surgical specialty recognized by the American Board of Medical Specialties
  • be in practice in one location for a number of years, with a background check, nomination, and interviews which verify that you are an ethical and safe surgeon among other criteria.

Hint: Look for the “FACS” (or “FRCS,” see below) after the “MD” in a doctor’s title or in his/her Curriculum Vitae to see if he/she is a “real surgeon.”

Note for patients in Canada: The equivalent of FACS in Canada is the Royal College of Physicians and Surgeons of Canada, FRCS.

3. Member of the American Society of Plastic Surgeons (ASPS)

The American Society of Plastic Surgeons is the largest organization of plastic surgeons in the United States and one of the largest in the world. ASPS members are uniquely qualified because of the society’s membership requirements:

Beware of physicians without this membership but belonging only to similar-sounding societies as their claim to excellence eg. “American Society of Cosmetic Surgery,” “Lipoplasty Society of North America,” etc.

4. Member of the American Society for Aesthetic Plastic Surgery (ASAPS)

This is the most elite society in the United States and perhaps the world for Aesthetic Plastic Surgery. To be a member means that your career is focused in cosmetic surgery at the highest level. Among the requirements for invitation and election to ASAPS membership, a plastic surgeon must:

  • Be certified by the American Board of Plastic Surgery (or in plastic surgery by the Royal College of Physicians and Surgeons of Canada);
  • Be in at least the third year of active practice following board certification;
  • Participate in accredited Continuing Medical Education (CME) to stay current with developments in the field of cosmetic plastic surgery and patient safety;
  • Document the performance of a significant number and variety of cosmetic surgical cases to demonstrate wide experience;
  • Be sponsored by two ASAPS-member plastic surgeons to help ensure that the applicant’s professional reputation meets the high standards required by ASAPS;
  • Adhere to current ethical standards for professional conduct as outlined in the Code of Ethics observed by all ASAPS-member surgeons;
  • Operate in accredited surgical facilities; and
  • Be elected by at least 80% of the Active Membership.

Find an ASPS member online.

5. Hospital privileges to perform the same type of surgery

Hospitals often examine qualifications of doctors applying for hospital staff privileges and restrict privileges to only surgeons best trained and qualified to do certain procedures. For example, in order for surgeons to be granted plastic surgery privileges in most hospitals in Orange County, California, that surgeon must have completed plastic surgery residency training and must be board-eligible or -certified in plastic surgery to be allowed to perform plastic surgical operations in that hospital.

Non-surgeons and other physicians that are not plastic surgeons circumvent this process by performing surgery in their offices or in outpatient surgery centers where the credentialing process is less rigorous or nonexistent. In these settings non-plastic surgeons perform procedures in which they have no formal residency training.

I am not warning against use of outpatient surgery centers or in-office procedures. I am only recommending that you check that your physician has hospital privileges for these same procedures.

6. Surgical Experience in the procedure you are having

Few patients ask how long doctors have been doing a certain procedure or how many they have performed. When you consult with a plastic surgeon:

  • Ask to see typical “before and after” photos;
  • discuss the details of the procedure in a manner that is clear to you;
  • review benefits and potential complications;
  • get full answers to your questions.

7. Evidence of Excellence, Experience and Commitment to the field of Plastic Surgery

Here are some additional criteria to look for in your plastic surgeon.

  • Surgical Board Certification in more than one field
  • Plastic Surgical Fellowships in addition to Plastic Surgical Residency.
  • Number of years practicing.
  • Peer Review Honors in their own board certification from groups such as Best Doctors, Top Doctors, Super Doctors.
  • Current or Prior position denoting excellence in the field or high regard by their peers such as:
    • Prior or present Professor or Faculty affiliation with a University Plastic surgical program (the higher the rank the better)
    • Chairman of a Department of plastic surgery at a regional hospital
    • Honors from surgical societies of which they are members such as Board Examiner, etc.
  • Published Plastic Surgical papers in peer review journals are also a good sign that they are committed to being on top of their field.

Feel Comfortable with your choice

It is very important that after you have done this screening and met with your potential surgeon that you feel confident in your choice.

Complications are not common in cosmetic surgery, but if one did occur are you confident that this surgeon would take charge and handle just about any problem?

Do you feel that he listens to you and communicates well by answering your questions completely, doesn’t rush you in to a decision but rather makes you part of the decision-making process? You should truly feel that it is a combined effort.

Does the surgeon’s office run smoothly? Do the staff take good care of you? If you answered in the affirmative and have gotten this far in your screening guidelines then I think you have found your “Dr. Right.”

—Larry S. Nichter, MD, FACS

Compression Garments are Important after Liposuction

Dr. Larry Nichter

A compression garment is required and beneficial after liposuction because:

  1. It restricts the amount of edema that forms and hastens its resolution by mechanical pressure.
  2. It decreases the amount of bruising.
  3. It assists the loose skin in retracting or shrinking.

It is common to have weight gain due to edema, serum that collects in the area, and the tumescent fluid that was injected. This will resolve over time. The more you wear the garment initially, the quicker this fluid resolves.

Edema: a condition characterized by an excess of watery fluid collecting in the cavities or tissues of the body.

The length of time that the garment should be worn varies depending on the amount of fat removed, the elastic nature of your skin, how much loose skin remains, and other factors. Your surgeon would give you the best advice, however this is the general routine for my patients.

The first garment should be fitted for you in the office prior to surgery and applied in the operating room. Often it will become loose as the edema is mobilized, and then it will need to be replaced. Spanx is a reasonable compression  garment if it gives enough support and is the right size. I have my patents bring them in so I can confirm that it fits well.

Most important advice is to listen to your surgeon, as he or she knows how much fat was removed, the elasticity that remains in your skin, and amount of skin redundancy.

I recommend that my patients wear their garments for a minimum of three weeks full time then for twelve hours at a time (day or night). If there is not a lot of redundant skin, this continues to a maximum of six weeks.

To be effective, the garment needs to fit snugly—but not too tight as that can make it difficult to sleep or cause pressure problems (inspect your skin when it is exposed if you are uncomfortable). As the edema resolves it is common for patients to switch to a smaller garment that fits. A Spanx-type garment would work fine, rather than ordering one or paying more at your doctor’s office.

—Dr. Larry Nichter, MD, FACS